150 TREATMENT PLANNING FOR PERIIMPLANT DISEASES POLYZOIS
Treatment Planning for Periimplant
Mucositis and Periimplantitis
reatment of periimplant diseases
T can be challenging, and as a result,
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careful consideration should be
given to a number of factors and param-
eters before the treatment commences.
The aim of this review was to propose
a simple and evidence-based step-by-step
process for treatment planning after
a diagnosis of periimplant mucositis
and/or periimplantitis. Treatment guide-
lines for periimplant diseases are evolv-
ing, and much of the proposed treatment
modalities are based on empirical evi-
dence. Existing evidence, however,
shows that periimplant mucositis is
reversible. Therefore, and since periim-
plant mucositis may develop into periim-
plantitis, early detection and treatment of
periimplant mucositis is of paramount
importance.1 Successful treatment of
periimplant mucositis will prevent its
progression to periimplantitis, which
can be challenging to manage even for
experienced clinicians.2
MATERIALS AND METHODS
A literature search was performed
in MEDLINE through PubMed data-
base of the US National Library of
Medicine, the Web of Science, and the
Cochrane library databases for articles
published until January 2018 using
Associate Professor\Consultant in Periodontology, Department
of Restorative Dentistry and Periodontology, Dublin Dental
University Hospital, Trinity College, Dublin, Ireland.
Reprint requests and correspondence to: Ioannis
Polyzois, PhD, DMD, Department of Restorative
Dentistry and Periodontology, Dublin Dental University
Hospital, Lincoln Place, Dublin 2, Ireland, Phone: 00
353 1 6127237, Fax: 00 353 1 6127297, E-mail: Ioannis.
Polyzois@dental.tcd.ie
ISSN 1056-6163/19/02802-150
Implant Dentistry
Volume 28  Number 2
Copyright © 2019 Wolters Kluwer Health, Inc. All rights
reserved.
DOI: 10.1097/ID.0000000000000869
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Ioannis Polyzois, PhD, DMD
Purpose: A literature search
was performed in a number of health
care databases for articles published
until January 2018.
Discussion: A number of ana-
tomical factors, risk indicators, pos-
sible aesthetic complications, and
financial implications have to be
taken into consideration before
treatment commences. When diag-
nosed early, periimplant mucositis is
a problem that can be easily man-
aged as long as the patient is
motivated and maintains good levels
of oral hygiene. Periimplantitis is
more difficult to treat and results can
be unpredictable. Nonsurgical ther-
apy has limited effectiveness on the
treatment of periimplantitis, but it
should always precede a surgical
Medical Subject Heading search terms
+ free text terms and in different combi-
nations. To be included in the article,
studies had to be written in English lan-
guage and published in an international
peer-reviewed journal.
REVIEW
Treatment Planning of
Periimplant Mucositis
Based on the consensus report of
workgroup 4 of the 2017 world work-
shop on the classification of periodontal
and periimplant diseases and condi-
tions, “the diagnosis of periimplant mu-
cositis requires presence of bleeding
and/or suppuration on gentle probing
with or without increased probing depth
compared to previous examinations.”
intervention. Clinically predictable
surgical outcomes seem to rely
mainly on the configuration of the
bone defect, the position of the
affected implant, and the patient’s
ability to perform good oral hygiene.
Conclusions: Thorough treat-
ment planning of periimplant dis-
eases is paramount for the success of
the treatment that follows. Local and
general factors as well as patients’
expectations have to be considered
before proceeding, but treatment
planning should also allow for
a degree of flexibility, which will
accommodate the unknown
parameters. (Implant Dent
2019;28:150–154)
Key Words: periimplant pocket,
infection, treatment plan
In addition, it requires “absence of bone
loss beyond crestal bone level changes
resulting from initial bone remodel-
ing.”3 When periimplant mucositis is
diagnosed, a treatment plan has to be
constructed to effectively resolve the
inflammation. A number of risk indica-
tors for the development of periimplant
mucositis have been identified over the
past few years including inadequate or-
al hygiene, not participating in mainte-
nance visits, remnants of cement, and
smoking. Other issues such as systemic
diseases, lack of keratinized tissue, and
abutment characteristics could contrib-
ute to the presenting inflammation and
should be taken into consideration.4
It is now well documented that
plaque accumulation at implants will
result in the development of periimplant
POLYZOIS
mucositis irrespective of surface char-
acteristics of the abutments/suprastruc-
tures.5 Available evidence also
indicates that resolution of inflamma-
tion usually occurs after treatment, but
surface characteristics might have a role
to play in the effectiveness of plaque
removal.6
If the inflammation is generalized,
around both natural teeth and implants,
then primary issues to investigate are
inadequate oral hygiene, smoking hab-
its, or presence of systemic diseases like
diabetes.
The patient should be scheduled to
have nonsurgical mechanical therapy,
start attending regular maintenance visits,
and to be encouraged to attend a smoking
cessation program. Because there is no
evidence to support the superiority of one
specific nonsurgical mechanical therapy
over another, the treating dentist can
select their preferred one, as long as this
method is not damaging to implant
surfaces and achieves efficient plaque
removal.7 Irrespective of the treatment,
effective plaque control by the patient is
paramount for treatment success. Both
manual and power-driven toothbrushes
in combination with regular use of
mouthwashes can be recommended. Dif-
ferent sizes of interdental brushes should
be tested, and only the ones that engage
all surfaces of the interproximal areas
should be used.8
When inflammation is present only
around one or more implants and the
prosthetic restorations are cemented, the
dentist should investigate for presence of
residual cement in the periimplant
pocket. If cement is present, this should
be removed. If it is not possible to
remove the cement nonsurgically with
the prosthetic construction in place, the
prosthetic construction needs to be
removed, and a surgical intervention
may be needed to facilitate cement
removal. Existing evidence suggests that
removal of excess cement has a positive
effect on the periimplant tissues.9
The clinician should examine the
prosthetic construction for poorly fitting
components or for design flaws that do
not allow accessibility for optimal oral
hygiene. If necessary, the prosthetic
construction has to be modified or re-
placed. When the prosthetic construction
is removed and before refitting, it would
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IMPLANT DENTISTRY / VOLUME 28, NUMBER 2 2019
Table 1. Local and General Factors That Have Been Proposed as Risk Indicators for
the Development of Periimplantitis
Local Factors
Oral hygiene
Residual cement\foreign body
Periimplant pocket depth
Implant surface characteristics
Prosthetic design
Periodontal health
Transmucosal abutment surface
characteristics
Type of connection
DENTAL PLAQUE ACCUMULATION AND
PATHOGENICITY
Local factors in general are related to clinical and anatomical characteristics, which can influence the accumulation and pathogenicity
of the dental plaque. General factors can influence the host’s susceptibility to the microbial challenge.
also be prudent to decontaminate the
internal well of the implant using chlo-
rhexidine gel. This way, bacterial micro-
leakage between the implant abutment
interface can be eliminated.8
Treatment Planning of Periimplantitis
In the 2017 world workshop on the
classification of periodontal and periim-
plant diseases, it was decided that
“diagnosis of periimplantitis requires
the presence of bleeding and/or suppu-
ration on gentle probing, increased
probing depth compared to previous ex-
aminations and presence of bone loss
beyond crestal bone level changes re-
sulting from initial bone remodeling.”
In the clinical situation where previous
examination data are not available,
“diagnosis of periimplantitis requires
probing depths of $6 mm and bone
levels $3 mm apical of the most coro-
nal portion of the intraosseous part of
the implant in addition to the presence
of bleeding and/or suppuration on gen-
tle probing.”3
Periimplantitis infections can be
divided into early and late. Early in-
fections may occur immediately after
the placement of the implant or during
the first number of weeks and while
osseointegration is being established.
This is mainly caused by contamination
at the time of surgery or exposure of the
implant during the healing phase. Late
infections occur after osseointegration
and restoration of the implants. There
are a several both local and general
factors that have been proposed as risk
151
General Factors
History of periodontitis
Environmental factors (smoking,
alcohol, etc)
Systemic diseases (diabetes, etc)
Genetics
HOST SUSCEPTIBILITY
indicators for the development of peri-
implantitis4 (Table 1).
Irrespective of when the infection
occurs, if radiographically, the implant
has a radiolucent line along the implant
surface, and the implant is tender to
percussion and/or mobile, then the only
option is removal of the implant.
Clinical and radiographic evalua-
tion of the implant in combination with
biomechanical testing of the implant/
bone interface to objectively assess the
mechanical stability of the affected
implant should give the clinician
enough information to develop an
appropriate treatment plan. Very low
resonance frequency analysis values or
very high damping capacity analysis
values in combination with very deep
probing depths and extensive radio-
graphic bone loss are usually an indi-
cation for implant removal.
If the decision is to retain the implant,
treatment should primarily focus on
controlling the infection. Nonsurgical
therapy should always be the first step
as this gives the clinician time to evaluate
the healing response of the tissues and the
patient’s ability to perform effective oral
hygiene measures. As the bone resorbs
and the periimplant pocket becomes
increasingly deeper, the effectiveness of
nonsurgical therapy decreases. If, how-
ever, an adequate oral hygiene cannot
be established, the indication for a surgi-
cal procedure must be questioned. For
patients for whom surgery is not indicated
or in areas where is difficult to get access
to decontaminate the periimplant pocket,
152 TREATMENT PLANNING FOR
alternative nonsurgical treatments should
be considered. In a number of studies,
mechanical therapy was supplemented
with topical antimicrobials. After such
combined therapy, somewhat better re-
sults were achieved for bleeding on prob-
ing and probing pocket depths.10–12
There is at present, however, limited evi-
dence that the use of Er:YAG lasers offer
an advantage over traditional mechanical
treatment.13
Overall, nonsurgical treatment of
implant surfaces in combination with
adequate oral hygiene can in some cases
be sufficient to control the infection
without any further surgical interven-
tion being necessary.12 In cases where
Fig. 1. A suggested decision tree, to aid in the treatment planning for periimplantitis.
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
PERIIMPLANT DISEASES
oral hygiene is not improving and the
infection cannot be controlled nonsur-
gically, the clinician might again have
to consider the removal of the implant
as the most appropriate way of manag-
ing this clinical problem. If the infection
cannot be controlled but adequate oral
hygiene is achieved, surgical therapy
should be considered (Fig. 1).
The aim of surgical therapy is to
provide adequate access for mechani-
cal debridement and chemical decon-
tamination of the implant surface.
Different surgical approaches have
been used in the treatment of periim-
plantitis including access surgery,
resective surgery, and regenerative
POLYZOIS
surgery with and without surface mod-
ification of the implant (implanto-
plasty). In aesthetic areas with
moderate bone loss and shallow bony
defects, access surgery (with or with-
out the use of systemic antibiotics)
should be considered, as it minimizes
the risk of recession. In addition, this
technique has been shown to be effec-
tive in reducing inflammation and
significantly reducing mean probing
depths.14 When residual bone is
uneven, resective surgery with or with-
out implantoplasty and apical position-
ing of the flaps has also been proven to
be successful.15,16 In cases where
defect morphology is favorable, 3- or
4-wall bony defects and regenerative
techniques may be warranted. Overall,
these regenerative techniques have
demonstrated varying degrees of suc-
cess, but when carefully planned in pa-
tients who can maintain good oral
hygiene, they can provide significant
amounts of regeneration.17,18 In addi-
tion, it has been demonstrated that
when the oral hygiene is maintained
at appropriate levels over time, the ini-
tial defect fill can be maintained.17
The choice of which approach to
choose is dependent on the defect type
and the position of the implant in the
oral cavity. Radiographic and clinical
examinations do not provide a complete
picture of the morphology of the bony
defect. As a result, the selection of the
most appropriate surgical procedure
can only be determined after elevation
of the flap and removal of granulation
tissue. If there are no aesthetic consid-
erations, an inverse bevel incision is
recommended to facilitate flap eleva-
tion and removal of a thin collar of
infected soft tissue around the implant.
If there are aesthetic considerations,
a crevicular/sulcular incision should
be used to preserve as much of the soft
tissue as possible.
After exposure of the periimplant
defect, a decision needs to be made
regarding the best surgical approach
(Fig. 2). To aid the clinicians in selecting
the appropriate surgical modality,
a group of researchers proposed a classi-
fication of the defect morphology.19–21
In general, in the presence of a crater-like
4-wall bony defect, 3-wall defect, and
a dehiscence type defect, regenerative
POLYZOIS
Fig. 2. A suggested decision tree, when planning a surgical intervention for treatment of
periimplantitis.
treatment modalities are recommended.
In 2-walled, one wall or horizontal de-
fects were the grafting material that can-
not be properly maintained, resective
surgery with apically positioned flap is
the treatment of choice.
Several methods are available to
mechanically debride the implant sur-
face. Hand instruments include cur-
ettes (plastic, metal, or titanium),
ultrasonic devices (with or without
a Teflon coating), and rotary titanium
brushes. Air powder abrasive devices
and lasers have also been used for
implant surface debridement.7 Despite
superior results when using metal cur-
ettes and ultrasonic tips in achieving
adequate surface debridement when
compared with nonmetallic instru-
ments, surface damage was more evi-
dent.22 When access is difficult, the
combined use of some of these instru-
ments is necessary for removal of cal-
cified deposits.
Mechanical decontamination dur-
ing the surgical procedure is followed
by chemical decontamination of the
exposed implant surface. Hydrogen
peroxide, chlorhexidine, citric acid,
hydrochloric acid, tetracycline, chlor-
amines, and sodium hypochlorite are
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
IMPLANT DENTISTRY / VOLUME 28, NUMBER 2 2019
some of the substances that have been
investigated for their effectiveness as
chemical decontaminants of the implant
surfaces. No single agent has, however,
been proven to be superior.23
A number of regenerative treat-
ment modalities have been proposed.
This includes placement of different
grafting materials with or without the
adjunctive use of membranes and the
use of membranes alone.8 As the stabil-
ity of the membrane can influence the
success of the regenerative procedure,
micropins should be used where the
morphology of the defect might not
allow for reasonable retention of the
grafting material.24 These micropins
can be removed at a later stage.
Maintenance is a key to the success
of the treatment of periimplant infec-
tions, and susceptible individuals
should be examined on a regular basis
and provided with the appropriate sup-
portive therapy.25 In a recent retrospec-
tive, observational study, it was
demonstrated that patients who had
been receiving 4-monthly supportive
therapy after surgical treatment of peri-
implantitis managed to maintain peri-
implant health in the long term (2–11
years).26
153
COMMENTS
If identified early, periimplant mu-
cositis is a problem, which in general
can be easily managed as long as the
patient is motivated and maintains good
levels of oral hygiene. On the other
hand, periimplantitis treatment is
unpredictable, possibly due to the fact
that the implant surface due to the rough
surface structure and presence of
threads is difficult to clean even during
surgical procedures. For these reasons
and before moving forward with a costly
treatment, the clinician should be con-
fident that the prosthetic construction is
well designed and possible to clean, that
no excess cement exists, and that the
patient is willing and capable to main-
tain a good oral hygiene. In addition, the
expectations of the patient should
weigh heavily on the proposed treat-
ment plan.
CONCLUSIONS
Thorough treatment planning of
periimplant mucositis and periimplan-
titis is paramount for the success of the
treatment that follows. Local and gen-
eral factors as well as patients’ expecta-
tion have to be considered before
proceeding, but treatment planning
should also allow for a degree of flexi-
bility, which will accommodate the
unknown parameters such as patients’
motivation and defect characteristics.
Although nonsurgical therapy may not
always be successful in advanced peri-
implantitis cases, it should always pre-
cede a surgical intervention. Overall,
clinically predictable outcomes of the
surgical interventions seem to rely
mainly on the configuration of the bone
defect, the position of the affected
implant, and the patient’s ability to per-
form good oral hygiene.
DISCLOSURE
The author claims to have no
financial interest, either directly or
indirectly, in the products or informa-
tion listed in the article.
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